Feb. 05, 2021
Iatrogenic ureteral injury is a potentially devastating complication of abdominal and pelvic surgery. The overall incidence of significant ureteral injury in gynecologic and colorectal surgeries has been estimated to be as high as 1.7% and 1.9%, respectively. Risk of injury is higher in patients with a complex history of radiation, prior surgery, inflammatory conditions or a mass that may obscure anatomic planes. In such cases ureteral identification is more challenging, even when measures (such as ureteral stenting) are taken to improve the ability to localize the ureter intraoperatively.
Following ureteral injury repair, the postoperative course can be prolonged due to the common need for urinary diversion in the form of ureteral stents, nephrostomy tubes or urethral catheters. Such instrumentation can cause flank pain, hematuria, irritative urinary tract symptoms and predisposition to urinary infections, all of which can significantly impact a patient's quality of life.
Patients who experience adverse outcomes often consider legal action to address their grievances. Multiple studies in gynecology have suggested that iatrogenic ureteral injuries, while uncommon, make up a disproportionate number of litigation claims. In fact, a group of Canadian authors whose research was published in Obstetrics and Gynecology in 2005 found a high relative risk of litigation (91, 95% confidence interval 55-158) in cases involving a urinary tract injury relative to nonurinary tract injuries.
Unsurprisingly, the economic impact of the medical malpractice system is enormous, with an estimated $55.6 billion spent annually on overall medical liability costs. Malpractice proceedings also have significant effects on physicians in regard to psychological stress, time, financial cost, professional reputation and personal life.
A 2018 study of Spanish physicians with a resolved claim in 2014 found that 81% of them experienced emotional distress. The study was published in the Journal of Healthcare Quality Research. Medical malpractice is an issue that will face many surgeons throughout their careers; Anupam B. Jena, M.D., Ph.D., and others, in research published in New England Journal of Medicine in 2011, found that 80% of surgeons were projected to face a claim by the age of 45.
David L. Sobel and others found in a 2006 survey of 683 urologists that 63% had been sued at least once in their careers, and that the average number of malpractice suits was 2.1 per urologist. Their research was published in Journal of Urology.
In many cases, malpractice litigation is not necessarily based on legitimate medical practice error, but rather the result of an understandable emotional reaction to a complicated medical scenario. A 2006 analysis of 1,452 claims across five insurers by David M. Studdert, LL.B., Sc.D., M.P.H, and others, published in New England Journal of Medicine, found that 37% of claims for injury were not due to medical error. Therefore, it is crucial to understand the factors associated with malpractice litigation to reduce the burden on patients, providers and the health care system.
Boyd R. Viers, M.D., a reconstructive urologist at Mayo Clinic in Rochester, Minnesota, and colleagues published a comprehensive examination of the literature related to iatrogenic ureteral injury in Urology in 2020. Dr. Viers and his co-authors employed the Westlaw legal database to identify a total of 522 cases from 1961-2019 for the study. Findings included:
- The most common specialty named in ureteral injury malpractice cases was gynecology (68.9%), followed by urology (17.4%).
- The most common claim was intraoperative negligence (90.8%).
- Of cases that went to trial, the verdict favored the defendant in over 70% of cases. The median award was $552,822.96 (interquartile range $187,007 to $1,063,603).
- Extended drainage duration, delayed surgical repair, claims of inadequate workup, and failure to supervise trainees were all significantly associated with an increased value of the award.
- Settlement was significantly more likely in cases involving an institution-only defendant, academic institutions and patient death.
"These findings serve to highlight factors perceived by patients and legal systems to be associated with significant distress or harm," says Dr. Viers. "Further work will explore the need for risk-mitigation strategies in accordance with trends in medicolegal decision-making."
For more information
Gilmour DT, et al. Disability and litigation from urinary tract injuries at benign gynecologic surgery in Canada. Obstetrics and Gynecology. 2005;105:109.
Gómez-Durán EL, et al. Physicians as second victims after a malpractice claim: An important issue in need of attention. Journal of Healthcare Quality Research. 2018;33:284.
Jena AB, et al. Malpractice risk according to physician specialty. New England Journal of Medicine. 2011;365:629.
Sobel DL, et al. Medical malpractice liability in clinical urology: A survey of practicing urologists. Journal of Urology. 2006;175:1847.
Studdert DM, et al. Claims, errors, and compensation payments in medical malpractice litigation. New England Journal of Medicine. 2006;354:2024.
Bole R, et al. Malpractice litigation in iatrogenic ureteral injury: A legal database review. Urology. 2020;146:19.